Plan Bupa Worldwide (*)

Transcripción

1 Plan Bupa Worldwide (*) Insured by / Asegurado por: Treating and caring for you as an individual Brindándole atención y servicio personalizado (*) Formerly known as Plan Amedex Worldwide

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3 AGREEMENT Bupa Insurance Company 7001 Southwest 97th Avenue Miami, Florida Website: Plan Bupa Worldwide (*) TABLE OF CONTENTS Page Agreement...1 Schedule of Benefits....2 Definitions...3 Policy Provisions...6 Administration Exclusions and Limitations...13 Bupa Insurance Company (hereinafter referred to as the Insurer ) agrees to pay you (hereinafter referred to as the Policyholder ) the benefits provided by this policy. All benefits are subject to the terms and conditions of this policy. Ten (10) Day Right To Examine The Policy: This policy may be returned within ten (10) days of receipt for a refund of all premiums paid, less an administrative fee of seventy-five dollars ($75). The policy may be returned to the Insurer or to the Policyholder s agent. If returned, the policy is void as though no policy had been issued. Important Notice About The Application: This policy is issued based on the application and payment of the premium. If any information shown on the application is incorrect or incomplete, or any information has been omitted, the policy may be rescinded, cancelled, or coverage may be modified, at the sole discretion of the Insurer. Eligibility: This policy can only be issued to residents of Latin America or the Caribbean who are a minimum of eighteen (18) years of age (except for eligible dependents) through a maximum of seventyfour (74) years of age. There is no maximum age for coverage under the same terms and conditions of this policy for those Insureds renewing a policy. Dependent coverage is available for the Policyholder s dependent children up to their nineteenth (19th) birthday, if single, or up to their twenty-fourth (24th) birthday, if single and full-time (minimum twelve (12) credits per semester) students of an accredited college or university at the time that the policy is issued and renewed. Coverage for such dependents continues through the next anniversary date of the policy following the attainment of nineteen (19) years of age, if single, or twenty-four (24) years of age if single and a full-time student. If a dependent child marries, discontinues being a full-time student after the nineteenth (19th) birthday, moves to another country, or if a dependent spouse ceases to be married to the Policyholder by reason of divorce or annulment, coverage for such dependent will terminate on the next anniversary date of the policy. Dependents who were covered under a prior policy with the Insurer and, who are otherwise eligible for coverage under their own separate policy, will be approved without underwriting for the same or higher deductible plan and with the same conditions and restrictions in existence under the prior policy which afforded them coverage with the Insurer. The application of the former dependent must be received before the end of the grace period of the policy which previously afforded the dependent coverage. Eligible dependents include the Policyholder s spouse or concubine, natural born children, legally adopted children, stepchildren, or children to whom the Policyholder has been appointed legal guardian by a court of competent jurisdiction, who have been identified on the application and for whom coverage is provided for under the policy. (*) Formerly known as Plan Amedex Worldwide 1 Plan Bupa Worldwide 0112

4 Commencement and ending of coverage Coverage begins at 00:01 hours Eastern Standard Time (U.S.A.) on the policy s effective date and terminates at 24:00 hours Eastern Standard Time (U.S.A.): (a) On the expiration date of the policy; or (b) Upon non-payment of the premium; or (c) Upon written request from the Policyholder to terminate the Policyholder s coverage; or (d) Upon written request from the Policyholder to terminate a dependent s coverage; or (e) Upon written notification from the Insurer, as allowed by the conditions of this policy. Requirement To Notify The Insurer The Insured Must Contact Bupa Insurance Company S Claims Administrator, Usa Medical Services, At Least Seventy-Two (72) Hours In Advance Of Receiving Any Medical Care. Emergency Treatment Must Be Notified Within Forty-Eight (48) Hours Of Commencement Of Such Treatment. If The Insured Fails To Contact Usa Medical Services As Stated Herein, The Insured Will Be Responsible For Thirty Percent (30%) Of All Covered Medical And Hospital Charges Related To The Claim, In Addition To The Plan s Deductible And Coinsurance (If Applicable). USA Medical Services can be contacted 24 hours a day, 365 days a year at the following telephone numbers: In the U.S.A.: (305) Free of charge from the U.S.A.: Fax: (305) address: claims@usamedicalservices.com Outside the USA: PHONE NUMBER CAN BE LOCATED ON YOUR ID CARD, OR AT Schedule Of Benefits (See Applicable Sections Of The Policy For Details, Limitations, And Restrictions). UNLESS OTHERWISE STATED HEREIN, INSUREDS UNDER THIS POLICY ARE NOT REQUIRED TO OBTAIN TREATMENT FROM THE PREFERRED PROVIDER NETWORK. Maximum Coverage Is Five Million Dollars ($5,000,000) Per Insured, Per Lifetime For All Covered MEDICAL AND HOSPITAL CHARGES, While The Policy Is In Force, Subject To The Limitations Herein. Coverage Maximum Benefit Preferred Provider Network Non-Preferred Provider Network 1. Standard private or semi-private hospital room and board No Limit $800 per day 2. Intensive care room and board No Limit $2,000 per day The following maximum benefits apply to all Providers: 3. Maternity care (except plans C Plus, D and E) (no deductible or coinsurance applies) $4, Newborn coverage (no deductible or coinsurance applies) $25, Congenital and hereditary disorders: Manifested before age 18 (per Insured, per lifetime) $250,000 Manifested on or after age 18 (per Insured, per lifetime) $5,000, Organ transplant (per Insured, per lifetime) $500, Air ambulance transportation (per Insured, per lifetime) $100, Ground ambulance transportation (per incident) $1,000 2 Plan Bupa Worldwide 0112

5 Coverage Maximum Benefit 9. Companion of hospitalized child (per admission) $1, Repatriation of mortal remains $5,000 Deductible One (1) deductible per Insured, per policy year up to a maximum of the out-of-country deductible. Maximum two (2) deductibles per policy per policy year. If an in-country deductible has been met, and services are then rendered out-of-country, the difference between the in-country and out-of-country deductible will be the Insured s responsibility. Any eligible charges incurred by the Insured during the last three (3) months of the policy year, which are used to satisfy that policy year s deductible, will be carried over and applied towards that Insured s deductible for the following policy year. Coinsurance The Insured is responsible for twenty percent (20%) of approved charges for the first five thousand dollars ($5,000) after satisfaction of the applicable deductible (except plans C Plus, D and E). One (1) coinsurance per Insured, per policy year. In the event of an accident involving multiple members of an insured family on the same policy, a maximum of two (2) coinsurances will be charged for this incident. Other coinsurance may be applicable for the members who were not charged coinsurance, for other illnesses or injuries not related to the accident. If USA Medical Services is notified in accordance with the policy requirements, then coinsurance will not apply to medical services in the country of residence. Definitions 1. ACCIDENT: Any sudden or unforeseen event produced by an external cause resulting in injury. 2. AIR AMBULANCE TRANSPORTATION: Emergency air transportation from the hospital where the Insured is admitted to the nearest suitable hospital where treatment can be provided. 3. AMENDMENT: A document added by the Insurer to the policy that clarifies, explains or modifies the policy. 4. ANESTHESIOLOGIST FEES: Charges made by an anesthesiologist for the administration of anesthesia during the performance of a surgical procedure or for medically necessary services for pain control. 5. ANNIVERSARY DATE: Annual occurrence of the effective date of the policy. 6. APPLICANT: The individual who executed the application for coverage. 7. APPLICATION: Written statements on a form by an Applicant about themselves and/or their dependents, used by the Insurer to determine acceptance or denial of the risk. Application includes any medical history, questionnaire, and other documents provided to or requested by the Insurer prior to the issuance of the policy. 8. ASSISTING PHYSICIAN/SURGEON FEES: Charges made by a physician or physicians who assist the principal surgeon in the performance of a surgical procedure. 9. CALENDAR YEAR: January 1st through December 31st of any given year. The insurer, USA Medical Services, and/or any of their applicable related subsidiaries and affiliates will not engage in any transactions with any parties or in any countries where otherwise prohibited by the laws in the United States of America. Please contact USA Medical Services for more information about this restriction. 10. CERTIFICATE OF COVERAGE: Document of the policy that specifies the commencement, conditions, extent and any limitations of the coverage, and lists each covered person. 11. CLASS: The Insureds of all policies of the same type, including but not limited to benefits, deductibles, age group, country, plan, year groups or a combination of any of these. 3 Plan Bupa Worldwide 0112

6 12. COINSURANCE: The portion of the covered medical bills an Insured must pay in addition to the deductible. 13. COMPLICATION OF BIRTH: Any disorder related to the birth of a newborn, not caused by genetic factors, manifested during the first thirty-one (31) days of life, including, but not limited to, hyperbilirubinemia (jaundice), cerebral hypoxia, hypoglycemia, prematurity, respiratory distress and birth trauma. date will only be effective after delivery of the insurance policy to the Policyholder and the expiration of the Ten (10) Day Right to Examine the Policy. 22. EMERGENCY: A medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured s life or physical integrity in immediate danger, if medical attention is not provided within twenty-four (24) hours. 14. CONGENITAL AND HEREDITARY DISORDERS OR ILLNESSES: Any disorder or illness existing before birth, regardless of its cause, whether or not manifested or diagnosed at birth, after birth or years later. 15. COUNTRY OF RESIDENCE: The country: (1) Where the Insured resides the majority of any calendar or policy year; or (2) Where the Insured has resided more than one hundred and eighty (180) continuous days during any three hundred and sixty five (365) day period while the policy is in force. 16. COVERED PREGNANCY: Covered pregnancies are those where the actual date of delivery is at least twelve (12) months after the effective date of coverage for the respective insured mother. Plans C Plus, D and E do not have covered pregnancies. 17. CUSTODIAL CARE: Assistance with the activities of daily living that can be provided by non-medical/nursing trained personnel (bathing, dressing, grooming, feeding, toileting, etc.). 18. DEDUCTIBLE: The amount of covered charges that must be paid by the Insured before policy benefits become payable. Charges incurred in the country of residence are subject to an in-country deductible. Charges incurred outside of the country of residence are subject to an out-of-country deductible. 19. DIAGNOSTIC MEDICAL CENTER: Medical facility licensed to perform comprehensive medical physical examinations. 23. EMERGENCY DENTAL TREATMENT: Treatment necessary to restore or replace sound natural teeth, damaged or lost in a covered accident. 24. emergency treatment: Medically necessary treatment due to an emergency. 25. GRACE PERIOD: The period of time of thirty (30) days after the policy due date during which the Insurer will allow the policy to be renewed. 26. GROUND AMBULANCE TRANSPORTATION: Emergency transportation to a hospital by ground ambulance. 27. HAZARDOUS ACTIVITIES: Any activity that exposes the participant to any foreseeable danger or risk. Examples of hazardous activities include but are not limited to: Aviation sports, rafting or canoeing involving white water rapids in excess of grade 5, tests of velocity, scuba diving at a depth of more than 30 meters, bungee jumping, participation in any extreme sport or participation in any sport for compensation or as a professional. 28. HOME HEALTH CARE: Care of the Insured in the Insured s home, which is prescribed and certified in writing by the Insured s attending physician, as required for the proper treatment of the illness or injury, and used in place of inpatient treatment in a hospital. Home Health Care includes the services of a skilled licensed professional (nurse, therapist, etc.) outside of the hospital and does not include Custodial Care. 20. DUE DATE: The date on which the premium is due and payable. 21. EFFECTIVE DATE: The date on which coverage under this policy begins and which is stated in the Certificate of Coverage. This 29. HOSPITAL: Any institution which is legally licensed as a medical or surgical facility in the country in which it is located, which is a) primarily engaged in providing diagnostic and therapeutic facilities for clinical and surgical diagnosis, treatment and care of injured and 4 Plan Bupa Worldwide 0112

7 sick persons by or under the supervision of a staff of physicians; and b) not a place of rest, a place for the aged or nursing or convalescent home or institution or a long term care facility. 30. HOSPITAL SERVICES: Hospital staff nurses, scrub nurses, standard private or semi-private room and board and other medically necessary treatments or services ordered by a physician for the Insured who is admitted to a hospital. Private nurse and standard private room upgrade to junior suite or suite are not included in Hospital Services. 31. ILLNESS: An abnormal condition of the body, manifested by signs, symptoms and/or abnormal findings in medical exams, which makes this condition different than the normal state of the body. 32. INJURY: Damage inflicted to the body by an external cause. 33. INSURED: An individual for whom an application has been completed, the premium paid, and for whom coverage has been approved by the Insurer and commenced. The term Insured includes the Policyholder and all dependents covered under this policy. 34. LABORATORY AND X-RAY SERVICES: Medically necessary X-ray services and laboratory testing used to diagnose or treat medical conditions. 36. NEWBORN: An infant from the moment of birth through the first thirty-one (31) days of life. 37. NURSE: An individual legally licensed to provide nursing care. 38. ORGAN TRANSPLANT: Surgical procedure in which an organ or tissue is inserted in a person s body (receptor) from a donor of the same species. 39. ORGAN TRANSPLANT PROVIDER NETWORK: A group of hospitals and physicians contracted on behalf of the Insurer for the purpose of providing organ transplant benefits to the Insured. The list of hospitals and physicians in the Organ Transplant Provider Network is available from USA Medical Services and may change at any time without prior notice. 40. OUTPATIENT SERVICES: Medical treatments or services provided or ordered by a physician for the Insured when the Insured is not admitted at a Hospital. Outpatient services may include services performed in a hospital or emergency room. 41. PHYSICIAN OR DOCTOR: A person who is legally licensed to practice medicine in the country where treatment is provided and while acting within the scope of their practice. Physician or Doctor shall also include a person legally licensed to practice as a dentist. 35. MEDICALLY NECESSARY: A treatment, service or medical supply which is determined by USA Medical Services to be necessary and appropriate for the diagnosis and/or treatment of an illness or injury. A treatment, service or supply will not be considered medically necessary if: (a) It is provided only as a convenience to the Insured, the Insured s family, or the provider (e.g. private nurse, standard private room upgrade to junior suite or suite, etc.); or (b) It is not appropriate for the Insured s diagnosis or treatment; or (c) It exceeds the level of care which is needed to provide adequate and appropriate diagnosis or treatment; or (d) Falls outside the standard of practice, as established by Professional Boards by discipline (MD, Physical Therapy, Nursing). 42. POLICYholder: The named applicant on the application for health insurance. This individual is the person entitled to receive reimbursement for covered medical expenses and the return of any unearned premium. 43. POLICY YEAR: The period of twelve (12) consecutive months beginning on the effective date of the policy and any subsequent twelve month period thereafter. 44. PRE-EXISTING CONDITION: A condition: (a) Which was diagnosed by a physician prior to the effective date of the policy or its reinstatement; or (b) For which medical advice or treatment was recommended by or received from a physician prior to the effective date of the policy or its reinstatement; or 5 Plan Bupa Worldwide 0112

8 (c) For which any symptom and/or sign, if presented to a physician prior to the effective date of the policy would have resulted in the diagnosis of an illness or medical condition. 45. PREFERRED PROVIDER NETWORK: A group of hospitals and physicians approved and contracted to treat Insureds on behalf of the Insurer. The list of hospitals and physicians in the Preferred Provider Network is available from USA Medical Services and may change at any time without prior notice. 46. PRESCRIPTION MEDICATIONS: Medications whose sale and use are legally restricted to the order of a physician. 47. PRIVATE AIRCRAFT: Any aircraft in a flight that is not regularly scheduled or chartered by a commercial airline. 48. RENEWAL DATE: The first day of the next policy year. The renewal date occurs only on the anniversary date of the policy. 49. RIDER: A document added to the policy by the insurer, which adds optional coverage. 50. SECOND SURGICAL OPINION: The medical opinion of a physician other than the current attending physician (approved and required by USA Medical Services). 51. USUAL, CUSTOMARY AND REASONABLE: The usual, customary and reasonable charges for provided medical services in a geographical area, regardless of whether direct payment or reimbursement was used. 52. WELL BABY CARE: Routine medical care provided to a healthy newborn. Policy Provisions 1. ANESTHESIOLOGIST FEES: Coverage for anesthesiologist fees must be approved in advance by USA Medical Services and is limited to the lesser of: (a) One hundred percent (100%) of the usual, customary and reasonable fee for the anesthesiology charges; or (b) Thirty percent (30%) of the usual, customary and reasonable principal surgeon s fee for the actual surgical procedure; or (c) Thirty percent (30%) of the fee approved for the principal surgeon for the surgical procedure; or (d) Special rates established for an area or country as determined by the Insurer. 2. ASSISTING PHYSICIAN/SURGEON FEES: Assisting physician/ surgeon fees are covered only when an assisting physician/surgeon is medically necessary for that operation and approved in advance by USA Medical Services. Assisting physician/surgeon fees are limited to the lesser of: (a) Twenty percent (20%) of the usual, customary and reasonable surgeon s fee for the actual surgical procedure; or (b) Twenty percent (20%) of the fee approved for the principal surgeon for the surgical procedure; or (c) If more than one assisting physician/surgeon is necessary, the maximum coverage for all assisting physicians/surgeons together shall not exceed twenty percent (20%) of the principal surgeon s fee for the actual surgical procedure; or (d) Special rates established for an area or country as determined by the Insurer. 3. HOME HEALTH CARE AND OUTPATIENT PHYSICAL THERAPY: An initial period of up to thirty (30) days will be covered if approved in advance by USA Medical Services. Any extension of up to thirty (30) days must also be approved in advance or the claim will be denied. Updated evidence of medical necessity and a treatment plan is required in advance to obtain each approval. 4. EMERGENCY DENTAL TREATMENT: Only emergency dental treatment that takes place within ninety (90) days of the date of a covered accident will be covered under this policy. 5. EMERGENCY TRANSPORTATION: Emergency transportation (by ground and air ambulance) is only covered if related to a covered condition for which treatment cannot be provided locally and transportation by any other method would result in loss of life or limb. Emergency transportation must be provided by a licensed and authorized transportation company to the nearest medical facility. 6 Plan Bupa Worldwide 0112

9 The vehicle or aircraft used must be staffed by medically trained personnel and must be equipped to handle a medical emergency. (a) Air ambulance transportation: (1) All air ambulance transportation must be pre-approved and coordinated by USA Medical Services. (2) The maximum amount payable for this benefit is one hundred thousand dollars ($100,000) per insured, per lifetime. (3) The Insured agrees to hold the Insurer, USA Medical Services, and any company affiliated with the Insurer or USA Medical Services by way of similar ownership or management, harmless from any negligence resulting from such services, or for delays or restrictions on flights caused by mechanical problems, by governmental restrictions, or by the pilot, due to operational conditions, or from any negligence resulting from such services. (b) Ground ambulance transportation: The maximum amount payable for this benefit is one thousand dollars ($1,000) per incident. 6. EXTENDED COVERAGE TO ELIGIBLE DEPENDENTS UPON DEATH OF POLICYHOLDER: In the event of the death of the Policyholder, the Insurer will provide continued coverage for the surviving dependents insured under this policy by affording two (2) years worth of coverage at no charge if the cause of the death of the Policyholder arose from a condition which would have been covered under this policy had the Policyholder survived. This benefit applies only to individuals remaining under the existing policy and will automatically terminate in the event of marriage of the remaining spouse or for surviving dependents who are not otherwise eligible for coverage under this policy and/or are issued their own separate policy. This extended coverage does not apply to any optional rider. 7. MATERNITY CARE: (Except plans C Plus, D and E) (a) There is a maximum benefit of four thousand dollars ($4,000) for each pregnancy with no deductible or coinsurance. (b) Pre and post-natal treatment, childbirth, complications of pregnancy or delivery, and well baby care are included in the maximum maternity benefit listed in this policy. (c) This benefit shall apply for covered pregnancies. Covered pregnancies are those where the actual date of delivery is at least twelve (12) months after the effective date of coverage for the respective insured mother. (d) There is no maternity coverage for dependent children. (e) Those Policyholders that were previously a dependent child under another policy with the Insurer must have maintained their own individual policy for a minimum of twelve (12) months to be eligible for this maternity care benefit. (f) The twelve (12) month waiting period for maternity coverage always applies regardless of whether or not the ninety (90) day waiting period for coverage under this policy has been waived. There is an optional rider available (except plans C Plus, D and E) to cover newborn and maternity complications. 8. NEWBORN COVERAGE: I. If born from a Covered Pregnancy: (a) Provisional coverage: If born from a covered pregnancy, each newborn will automatically be covered for complications of birth, and any injury or illness for the first ninety (90) days after birth up to a maximum of twenty-five thousand dollars ($25,000) with no deductible or coinsurance. (b) Permanent coverage: For permanent coverage of a child born from a covered pregnancy, a Notification of Birth consisting of the newborn s full name, gender and date of birth must be submitted within ninety (90) days of birth. Effective as of the date of birth, coverage with applicable deductible and coinsurance will then be up to the policy limits. Policy limits for complications of birth relating to a newborn are limited to the maximum benefits described in provision 8. I.(a). The premium for the addition is due at the time of the notification of birth. If such notification is not received within 90 days of birth, then an application for insurance is required on the addition and will be subject to underwriting. 7 Plan Bupa Worldwide 0112

10 (c) Well baby care: Only covered as stated in the Maternity Care provision of this policy. II. If NOT born from a Covered Pregnancy, there is no provisional coverage for the newborn. To add a newborn to the policy, payment of the premium and submission of a completed application for insurance which is subject to underwriting by the Insurer, are required. 9. CONGENITAL AND HEREDITARY DISORDERS: Coverage under this policy for congenital and hereditary disorders is as follows: (a) The lifetime maximum benefits for any congenital and hereditary disorders that manifest themselves before the insured s eighteenth (18th) birthday are: i. Two hundred fifty thousand dollars ($250,000) per person, including any benefits already paid on an existing policy or rider, after deductible and co-insurance (if applicable), for any congenital and hereditary disorders that initially manifest themselves on or after your policy anniversary date occurring on or after August 1, 2003; ii. Twenty five thousand dollars ($25,000) per person up to the insured s eighteenth (18th) birthday, including any benefits already paid on an existing policy or rider, for insureds born from a covered pregnancy only, when the congenital and hereditary disorders initially manifest themselves prior to your policy anniversary date occurring on or after August 1, (b) The lifetime maximum benefits for any congenital and hereditary disorders that manifest themselves on or after the insured s eighteenth (18th) birthday and subsequent to your policy anniversary date on or after January 1, 2000 are equal to the maximum policy limits herein, after deductible and co-insurance (if applicable). 10. ORGAN TRANSPLANTS: Coverage for transplantation of human organs and tissues is provided only within the Insurer s Organ Transplant Provider Network. There is no coverage outside the Organ Transplant Provider Network. The maximum amount payable for this benefit is five hundred thousand ($500,000) per Insured, per lifetime. This organ transplant benefit begins once the need for transplantation has been determined by a provider, has been certified by a second surgical or medical opinion and has been approved by USA Medical Services, and is subject to all the terms, provisions and exclusions of the policy. This benefit includes: (a) Pre-transplant care, which includes those services directly related to evaluation of the need for transplantation, evaluation of the Insured for the transplant procedure, and preparation and stabilization of the Insured for the transplant procedure. (b) Pre-surgical workup, including all laboratory and X-ray exams, CT scans, Magnetic Resonance Imaging (MRI s), ultrasounds, biopsies, scans, medications and supplies. (c) The costs of organ procurement, transportation, and harvesting up to a maximum of twenty-five thousand dollars ($25,000), which is included as part of the maximum organ transplant benefit. (d) Post-transplant care including, but not limited to any follow-up, medically necessary treatment resulting from the transplant, and any complications that arise after the transplant procedure, whether a direct or indirect consequence of the transplant. (e) Any medication or therapeutic measure used to ensure the viability and permanence of the transplanted organ. (f) Any home health care, nursing care (e.g. wound care, infusion, assessment, etc.), emergency transportation, medical attention, clinic or office visits, transfusions, supplies, or medications related to the transplant. 11. PRESCRIPTION DRUGS: Prescription drugs are only covered if first prescribed during a hospitalization or after outpatient surgery and for a maximum period of six (6) months, unless the Insurer approves an extension. In all cases, a copy of the prescription from the attending physician must accompany the claim. 12. SPECIAL TREATMENTS: Prosthesis, orthotic devices, durable medical equipment, implants, radiation therapy chemotherapy and highly specialized drugs (e.g. Interferon, Procrit, Avonex, Embrel, etc.) will be covered, but must be approved and coordinated in advance by USA Medical Services. Special treatments will be provided by the Insurer or reimbursed at the cost that the Insurer would have incurred if purchased from its providers. 8 Plan Bupa Worldwide 0112

11 13. PRE-EXISTING CONDITIONS: Pre-existing conditions fall into two (2) categories: (a) Disclosed at the time of the application: i. Free of symptoms, signs and treatment during the five (5) year period prior to the effective date of the policy, are covered upon expiration of the ninety (90) days waiting period, unless specifically excluded by an amendment to the policy. ii. With symptoms, signs or treatment any time during the five (5) year period prior to the effective date of the policy, will be covered after two years from the effective date of the policy, unless specifically excluded by an amendment to the policy. (b) Not disclosed at the time of application: Pre-existing conditions not disclosed at the time of the application will NEVER be covered during the lifetime of the policy. Furthermore, the Insurer retains the right to rescind, cancel or modify the policy based on the Insured s failure to disclose any such conditions. 14. ILLNESS OR INJURY IN A PRIVATE AIRCRAFT: Any illness or injury sustained as a passenger in a Private Aircraft is covered up to a maximum of two hundred and fifty thousand dollars ($250,000) per Insured, per lifetime. There is an optional rider available to cover private pilot and crew members. 15. REPATRIATION OF MORTAL REMAINS: In the event an Insured dies outside of his/her country of residence, the Insurer will pay up to five thousand dollars ($5,000) toward repatriation of the deceased s remains to the deceased s country of residence if the death resulted from a condition which would have been covered under the terms of the policy had the Insured survived. Coverage is limited to only those services and supplies necessary to prepare the deceased s body and to transport the deceased to his country of residence. Arrangements must be coordinated in conjunction with USA Medical Services. 16. COMPANION OF HOSPITALIZED CHILD: Charges incurred and included in the hospital bill for overnight accommodations in the hospital for the companion of a hospitalized insured child under the age of eighteen (18) will be payable up to one hundred dollars ($100) per day up to a maximum of one thousand dollars ($1,000) per hospital admission. 17. REQUIRED SECOND SURGICAL OPINION: If a surgeon has recommended that an Insured undergo any non-emergency surgical procedure, the Insured must notify USA Medical Services at least seventy-two (72) hours prior to the scheduled procedure. If a second surgical opinion is deemed necessary by either the Insurer or USA Medical Services, it must be conducted by a physician chosen and arranged by USA Medical Services. Only those second surgical opinions required and coordinated by USA Medical Services are covered. In the event the second surgical opinion contradicts or does not confirm the need for surgery, the Insurer will also pay for a third surgical opinion from a physician chosen by USA Medical Services. If the second or third surgical opinion confirms the need for surgery, benefits for the surgery will be paid according to this policy. IF THE INSURED DOES NOT OBTAIN A REQUIRED SECOND SURGICAL OPINION, THE INSURED WILL BE RESPONSIBLE FOR thirty percent (30%) OF ALL COVERED MEDICAL AND HOSPITAL CHARGES RELATED TO THE CLAIM IN ADDITION TO THE PLAN DEDUCTIBLE AND COINSURANCE (IF APPLICABLE). 18. OUTPATIENT SERVICES: Coverage is only provided when medically necessary. 19. MAXIMUM HOSPITAL STAY: The maximum hospital stay for any specific illness or injury or any related treatment is one hundred and eighty (180) days during the next three hundred and sixty five (365) days after the first admission. 20. NOSE & NASAL SEPTUM deformity: When nose or nasal septum deformity is induced by a trauma in a covered accident, surgical treatment will only be covered if authorized in advance by USA Medical Services. The evidence of trauma in the form of fracture must be confirmed radiographically (X-rays, CT scan, etc.). 21. WAITING PERIOD: This policy contains a ninety (90) day waiting period, during which, only illnesses or injuries caused by an accident occurring within this period, or disease of infectious origin that first manifested itself within this period will be covered. 9 Plan Bupa Worldwide 0112

12 22. WAIVING OF WAITING PERIOD: The Insurer will waive the waiting period only if: (a) Other medical expense insurance was in force with another company for the Insured for at least one (1) continuous year; and (b) The effective date of this policy commences within thirty (30) days of the expiration of the previous coverage; and (c) The prior coverage is disclosed in the application for insurance; and (d) We receive the prior policy and a copy of the receipt for the last year s premium payment, with the application. If the waiting period is waived, benefits payable for any condition incurred during the first ninety (90) days of coverage are limited, while the policy is in force, to the lesser benefit provided either by this policy or the prior policy. ADMINISTRATION 1. AUTHORITY: No agent has the authority to change the policy or to waive any of its provisions. After issue, no change in the policy shall be valid unless approved in writing by an officer or the Chief Underwriter of the Insurer and such approval is endorsed by an amendment to the policy. 2. CHANGES OF COUNTRY OF RESIDENCE: The Insured must notify the Insurer in writing of any change of the Insured s country of residence within thirty (30) days of its occurrence. Changes of residence outside the Insured s stated country of residence will, at the Insurer s discretion, result in modification of coverage or cancellation of the policy. Changes of residence to the U.S.A. will result in non-renewal of the policy. Failure to notify the Insurer of any change of the Insured s country of residence may result in cancellation of the policy or modification of coverage on the next anniversary date, at the Insurer s discretion. THE INSURED S COUNTRY OF RESIDENCE CANNOT BE THE UNITED STATES OF AMERICA. 3. COMMENCEMENT OF INSURANCE: Subject to the provisions of this policy, benefits begin on the Effective Date of the policy and not on the date of application for insurance. 4. OTHER INSURANCE COVERAGE: When another policy is in existence which provides benefits also covered by this policy, benefits will be coordinated. All claims incurred in the country of residence must be made in the first instance against the other policy. This policy shall only provide benefits when such other benefits payable under the other policy have been exhausted. Outside the country of residence, Bupa Insurance Company will function as the primary Insurer and retains the right to collect any payment from local or other insurers. 5. ENTIRE CONTRACT/CONTROLLING CONTRACT: The policy, the application, the Certificate of Coverage and any riders or amendments thereto, shall constitute the entire contract between the parties. The Spanish translation is provided for the convenience of the Insured. The English version of this policy will prevail and is the controlling contract in the event of any question or dispute regarding this policy. 6. PAYMENT OF CLAIMS: It is the Insurer s policy to make payments directly to physicians and hospitals worldwide. When this is not possible, the Insurer will reimburse the Policyholder the contractual rate given to the Insurer by the provider involved and/or in accordance with the usual, customary, and reasonable fees for that geographical area, whichever is less. Any charges or portions of charges in excess of these amounts are the responsibility of the Insured. If a Policyholder is not living, the Insurer will pay any unpaid benefits to the estate of the deceased Policyholder. USA Medical Services must receive the complete medical and non-medical information they require in order to determine compensability before: 1. Approve a direct payment; or 2. Reimburse the policyholder. The insurer, USA Medical Services, and/or any of their applicable related subsidiaries and affiliates will not engage in any transactions with any parties or in any countries where otherwise prohibited by the laws in the United States of America. Please contact USA Medical Services for more information about this restriction. 7. CURRENCY: All currency values stated in this policy are in U.S. dollars. 10 Plan Bupa Worldwide 0112

13 8. PHYSICAL EXAMINATIONS: The Insurer, at its own expense, shall have the right and opportunity to examine any Insured whose illness or injury is the basis of a claim, when and as often as considered necessary by the Insurer during the pendency of the claim. In the case of death, the Insurer has the right to request an autopsy at a facility of its choice. 9. DUTY TO COOPERATE: The Insured shall make available to the Insurer all medical reports and records and, when requested by the Insurer, shall sign all authorization forms necessary for the Insurer to obtain such medical reports and records. Failure to cooperate with the Insurer or failure to authorize the release of all medical records requested by the Insurer may cause a claim to be denied. 10. POLICY CANCELLATION OR NON-RENEWAL: The Insurer retains the right to cancel, modify or rescind the policy if statements on the application are found to be misrepresentations, incomplete or that fraud has been committed, leading the Insurer to approve an application when, with the correct or complete information, the Insurer would have issued a policy with restricted coverage or declined to provide insurance. The Insurer retains the right to cancel or modify a policy in terms of rates, deductibles or benefits, generally and specifically, if the Insured changes country of residence, regardless of how many years the policy has been in force. If an Insured resides in the U.S.A. on a continuous basis for more than one hundred and eighty (180) days during any three hundred and sixty five (365) day period regardless of the type of visa issued to the Insured for that purpose, then coverage for any condition will be limited to the Insurer s Preferred Provider Network until the policy s next renewal date at which time the policy will automatically terminate. Submission of a fraudulent claim is also grounds for rescission or cancellation of the policy. The Insurer retains the right to cancel, non-renew or modify a policy on a class basis as defined in this policy. No individual Insured shall be independently penalized by cancellation or modification of the policy due solely to a poor claim record POLICY ISSUANCE: This policy cannot be issued or delivered in the U.S.A., except as may be specifically permitted under the laws of the State of Florida. The policy is deemed issued or delivered upon receipt of the policy by the Policyholder in his/her country of residence. 12. POLICY MODE: All policies are deemed annual policies. Premiums are to be paid annually, unless the Insurer authorizes other modes of payment. 13. PREMIUM PAYMENT: Payment of the premium on time is the responsibility of the Policyholder. The premium is due on the renewal date of the policy or other due dates if authorized by the Insurer. Premium notices are provided as a courtesy and the Insurer provides no guarantee of delivering premium notices. If a Policyholder has not received a premium notice thirty (30) days prior to the due date and the Policyholder does not know the amount of the premium payment, the Policyholder should contact his/her agent or the Insurer. Payment may also be made online ( 14. PREMIUM RATE CHANGES: The Insurer retains the right to change the premium at the time of each renewal date. This right will be exercised on a class basis only upon the renewal date of each respective policy. 15. PROOF OF CLAIM: Written proof of loss consisting of ORIGINAL itemized bills, medical records and claim form properly completed and signed must be furnished to USA Medical Services at 7001 Southwest 97th Avenue, Miami, Florida 33173, within one hundred and eighty (180) days after the treatment or service date. Failure to do so will result in the claim being denied. A completed claim form is required for all claims submitted per incident. Claim forms are furnished with the policy or may be obtained by contacting your agent or USA Medical Services at the address shown herein or through our website ( Bills received in currencies other than U.S. dollars will be processed in accordance with the official exchange rate, as determined by the Insurer, on the date of service. After their nineteenth (19th) birthday dependent insureds must provide a certificate or affidavit from the college or university as evidence that they were full-time students at the time the policy was issued or renewed, AND written statement signed by the Policyholder that the dependent s marital status is single. Plan Bupa Worldwide 0112

14 16. REFUNDS: If a Policyholder or the Insurer cancels the policy after it has been issued, reinstated or renewed, the Insurer will refund the unearned portion of the premium, less administrative charges and policy fees, to a maximum of sixty-five percent (65%) of the premium. The policy fee, USA Medical Services fee and thirtyfive percent (35%) of the base premium are non-refundable. The unearned portion of the premium is based on the number of days corresponding to the payment mode, minus the number of days the policy was in force. 17. GRACE PERIOD: If premium is not received by the due date, the Insurer will allow a grace period of thirty (30) days from the due date for the premium to be paid. If the premium is not received by the Insurer prior to the end of the grace period, this policy and all of its benefits will be deemed terminated as of the original due date of the premium. Benefits are not provided under the policy during the grace period. 18. REINSTATEMENT: If the policy was not renewed within the Grace Period, it can be reinstated in the following 60 (sixty) days after the grace period ends if the insured provides new evidence of insurability consisting of a new application and any other information or document required by the Insurer. All policies reinstated after the thirty (30) day grace period are deemed new policies with no antiquity or credit being afforded to the Insured. All medical conditions existing prior to the date of reinstatement of the policy shall be deemed and treated as pre-existing conditions under this policy. No reinstatement will be authorized ninety (90) days after the date of termination of the policy. 19. CLAIMS APPEALS: In the event of any disagreement between the Insured and the Insurer regarding this Insurance Policy and/ or its provisions, the Insured, before commencing any arbitration or legal proceedings, shall request a review of the matter by the Bupa Insurance Company Appeals Committee. In order to begin such a review, the Insured must submit a written request to the Appeals Committee. This request shall include copies of all relevant information sought to be considered, as well as an explanation of what decision should be reviewed and why. Said appeals shall be sent to the attention of the Bupa Insurance Company Appeals Coordinator, c/o USA Medical Services. Upon the submission of a request for review, the Appeals Committee will determine whether any further information and/or documentation is needed and act to timely obtain such. Within thirty (30) days thereafter, the Appeals Committee will notify the Insured of its decision and the underlying rationale. 20. ARBITRATION, LEGAL ACTIONS, AND JURY WAIVER: Any disagreement that may persist upon completion of the claims appeal as determined herein, must first be submitted to arbitration. In such cases, the Insured and the Insurer will submit their difference to three (3) arbiters: Each party selecting an arbiter, and the third arbiter to be selected by the arbiters named by the parties herein. In the event of disagreement between the arbiters, the decision will rest with the majority. Either the Insured or the Insurer may initiate arbitration by written notice to the other party demanding arbitration and naming its arbiter. The other party shall have twenty (20) days after receipt of said notice within which to designate its arbiter. The two (2) arbiters named by the parties, within ten (10) days thereafter, shall choose the third arbiter and the arbitration shall be held at the place hereinafter set forth ten (10) days after the appointment of the third arbiter. If the other party does not name its arbiter within twenty (20) days, the complaining party may designate the second arbiter and the other party shall not be aggrieved thereby. Arbitration shall take place in Miami-Dade County, Florida, U.S.A. or if approved by the Insurer, in the Policyholder s country of residence. The expenses of the arbitration shall be shared equally between the parties. The Insured confers exclusive jurisdiction in Miami-Dade County, Florida for determination of any rights under this policy. The Insurer and any Insured covered by this policy hereby expressly agree to trial by judge in any legal action arising directly or indirectly from this policy. The Insurer and the Insured further agree that each party will pay their own attorneys fees and costs, including those incurred in arbitration. 21. SUBROGATION AND INDEMNITY: The Insurer has a right of subrogation or reimbursement from an Insured to whom it has paid any claims to or on behalf of, if such Insured has recovered all or part of such payments from a third party. Furthermore, the Insurer has the right to proceed at its own expense in the name of the Insured, against third parties who may be responsible for causing a claim under this policy or who may be responsible for providing indemnity of benefits for any claim under this policy. 12 Plan Bupa Worldwide 0112

15 22. TERMINATION OF COVERAGE UPON TERMINATION OF POLICY: In the event a policy terminates for any reason, coverage ceases on the effective date of the termination and the Insurer will only be responsible for treatment covered under the terms of the policy that took place before the effective date of termination of the policy. There is no coverage for any treatment that occurs after the effective date of the termination, regardless of when the condition first occurred or how much additional treatment may be required. 23. CHANGE OF PLAN OR DEDUCTIBLE: At any anniversary date, the Policyholder can request to change a plan or deductible. Some requests are subject to underwriting evaluation. During the first ninety (90) days from the effective date of the change, benefits payable for any illness or injury not caused by accident or disease of infectious origin, will be limited to the lesser of benefits provided by the new plan or the prior plan. During the first twelve (12) months after the effective date of the change, maternity, newborn, congenital and organ transplant benefits will be limited to the lesser benefit provided by either the new plan or prior plan. EXCLUSIONS and LIMITATIONS This policy does not provide coverage or benefits for any of the following: 1. Treatment of any illness, injury, or any charges arising from any treatment, service or supply which is: (a) Not medically necessary; or (b) For an Insured who is not under the care of a physician, doctor or skilled professional; or (c) Not authorized or prescribed by a physician or doctor; or (d) Custodial care. 2. Any care or treatment, while sane or insane, received due to self inflicted illness or injury, suicide, failed suicide, alcohol use or abuse, drug use or abuse, or the use of illegal substances or illegal use of controlled substances. This includes any accident resulting from any of the aforementioned criteria. 3. Routine eye and ear examinations, hearing aids, eye glasses, contact lenses, radial keratotomy and/or other procedures to correct eye refraction disorders. 4. Any medical examination or diagnostic study which is part of a routine physical examination, including vaccinations and the issuance of medical certificates and examinations as to the suitability for employment or travel. 5. Chiropractic care, homeopathic treatment, acupuncture or any type of alternative medicine. 6. Any illness or injury not caused by an accident or a disease of infectious origin which first manifested within the first ninety (90) days from the effective date of the policy. 7. Elective or cosmetic surgery or medical treatment which is primarily for beautification, unless necessitated by injury, deformity or illness which first occurs while the Insured is covered under this policy. This also includes any surgical treatment for nasal or septal deformity that was not induced by trauma, except as provided for in this policy. 8. Any charges in connection with pre-existing conditions, except as defined and addressed in this policy. 9. Any treatment, service or supply that is not scientifically or medically recognized for the prescribed treatment or which is considered experimental and/or not approved for general use by the Food and Drug Administration of the U.S.A. 10. Treatment in any governmental facility or any expense if the Insured would be entitled to free care. Service or treatment for which payment would not have to be made had no insurance coverage existed. 11. Diagnostic procedures or treatment of mental illnesses and/or psychiatric, behavioral or developmental disorders, Chronic Fatigue Syndrome, sleep apnea and any other sleep disorders. 12. Any portion of any charge that is in excess of the usual, customary and reasonable charge for the particular service or supply for the geographical area. 13 Plan Bupa Worldwide 0112

16 13. Any expense for male or female sterilization, reversal of sterilization, sex change, sexual transformation, birth control, infertility, artificial insemination, sexual dysfunction or inadequacies, disorders related to Human Papillomavirus (HPV) and/or sexually transmittable disease. 24. Acquired Immune Deficiency Syndrome (AIDS), HIV positive or AIDS related illnesses. 25. An elective admission more than twenty-three (23) hours before a planned surgery, unless authorized in writing by the Insurer. 14. Treatment or service for any medical, mental or dental condition related to or arising as a complication to those medical, mental or dental services or other conditions specifically excluded by an amendment to or not covered by this policy. 15. Any expense, service or treatment for obesity, weight control or any form of food supplement. 16. Podiatric care to treat functional disorders of the structures of the feet, including but not limited to, corns, calluses, bunions, Hallux valgus, hammer toe, Morton s neuroma, flat feet, weak arches, and weak feet, including pedicures, special shoes and inserts of any type or form. 17. Treatment by a bone growth stimulator, bone growth stimulation or treatment relating to growth hormone, regardless of the reason for prescription. 26. Treatment of the upper maxilla, the jaw or jaw joint disorders, including, but not limited to, jaw anomalies, malformations, temporomandibular joint syndrome, craniomandibular disorders, or other conditions of the jaw or jaw joint linking the jaw bone and the skull and complex of muscles, nerves and other tissue relating to that joint. 27. Treatment by the spouse, father, mother, brother, sister or child of any insured under this policy. 28. Over the counter or non-prescription drugs, prescription medications which are not first prescribed while the Insured is admitted in a hospital and prescription medications which are not prescribed as part of follow-up treatment after outpatient surgery. 29. Personal or home-based artificial kidney equipment, unless authorized in writing by the Insurer. 18. Treatment for injuries resulting from participation in any hazardous activities as a professional or for compensation. 30. Treatment for injury sustained while traveling as a pilot or crewmember in a private aircraft. 19. All treatment to a mother or to a newborn related to a non- covered pregnancy. 20. Any voluntarily induced termination of pregnancy, unless imminent maternal demise is apparent. 21. Any congenital or hereditary disorder or illness, except as provided for under the provisions of this policy. 31. Cost relating to the acquisition and implantation of artificial heart, mono or bi-ventricular devices, other artificial or animal organs and all expenses of any cryopreservation of more than twenty-four (24) hours duration. 32. Injury or illness caused by, or related to ionized radiation, pollution or contamination, radioactivity from any nuclear material, nuclear waste, or the combustion of nuclear fuel or nuclear devices. 22. Any dental treatment or services not related to a covered accident or beyond 90 days from the date of such accident. 23. Treatment of injuries resulting while in service as a member of a police or military unit, or from participation in war, riot, civil commotion, or any illegal activity, including resultant imprisonment. 14 Plan Bupa Worldwide 0112

17 Bupa Insurance Company 7001 Southwest 97th Avenue Miami, Florida Website: Plan Bupa Worldwide (*) CONTENIDO Página Acuerdo...1 Tabla de Beneficios...2 Definiciones....3 Provisiones de la Póliza...6 Administración Exclusiones y Limitaciones ACUERDo Bupa insurance company (de ahora en adelante denominada el Asegurador ) acuerda pagar a usted (de ahora en adelante denominado el Asegurado ) los beneficios estipulados en esta póliza. Todos los beneficios están sujetos a los términos y condiciones de esta póliza. Derecho de diez (10) días para examinar la póliza: Esta póliza puede ser devuelta dentro de los diez (10) días siguientes a su recibo para el reembolso de todas las primas pagadas menos un costo administrativo de setenta y cinco dólares ($75). La póliza puede ser devuelta al Asegurador o al agente del Asegurado. De ser devuelta, la póliza será considerada nula como si nunca se hubiese emitido. AVISO IMPORTANTE SOBRE LA SOLICITUD: Esta póliza es emitida basada en la solicitud y el pago de la prima. Si alguna información en la solicitud está incorrecta o incompleta, o alguna información ha sido omitida, la póliza será rescindida, cancelada o la cobertura será modificada a la sola discreción del Asegurador. ELEGIBILIDAD: Esta póliza sólo puede ser emitida a residentes de América Latina y el Caribe con una edad mínima de dieciocho (18) años (excepto para los dependientes elegibles) hasta un máximo de setenta y cuatro (74) años de edad. No hay edad máxima para cobertura bajo los mismos términos y condiciones de esta póliza para aquellos asegurados que renuevan una póliza. La cobertura está disponible para los hijos dependientes del Asegurado, hasta cumplir los diecinueve (19) años de edad, si son solteros, o hasta los veinticuatro (24) años de edad, si son solteros, y estudiantes a tiempo completo (mínimo doce (12) créditos por semestre) en un colegio o universidad acreditada en el momento en que la póliza es emitida o renovada. La cobertura para dichos dependientes continúa hasta la próxima fecha de aniversario de la póliza, siguiente al cumplimiento de los diecinueve (19) años de edad, si son solteros, o hasta los veinticuatro (24) años de edad, si son solteros, y estudiantes a tiempo completo. Si un hijo(a) dependiente contrae matrimonio, deja de ser un estudiante a tiempo completo, después del décimo-noveno (19º) cumpleaños, cambia de país de residencia, o si un cónyuge dependiente deja de estar casado con el Asegurado por razón de divorcio o anulación, la cobertura para estos dependientes terminará en la fecha del próximo aniversario de la póliza. Los dependientes que han estado cubiertos bajo una póliza anterior emitida por el Asegurador y que sean elegibles para cobertura bajo su propia póliza, serán aprobados sin selección de riesgos para una póliza con el mismo o con mayor deducible y con las mismas condiciones y restricciones en existencia en la póliza anterior bajo la cual tuvo cobertura con el Asegurador. La solicitud del dependiente debe ser recibida antes de terminar el período de gracia de la póliza bajo la cual tuvo cobertura con el Asegurador. Dependientes elegibles incluyen el cónyuge o concubina del Asegurado, hijos, hijos adoptados legalmente, hijastros o menores para los cuales el Asegurado ha sido designado como tutor legal por una corte de jurisdicción competente, que hayan sido identificados en la solicitud y para los cuales se provee cobertura bajo la póliza. 1 (*) Antes conocido como Plan Amedex Worldwide Plan Bupa Worldwide 0112

18 Comienzo y terminación de la cobertura La cobertura comienza a las 00:01 horas Estándar del Este (EE.UU.) en la fecha efectiva de la póliza y termina a las 24:00 horas Estándar del Este (EE.UU.): (a) En la fecha de expiración de la póliza; o (b) Por el no pago de la prima; o (c) A pedido por escrito del Asegurado principal de terminar la cobertura; o (d) A pedido por escrito del Asegurado principal de terminar la cobertura para algún dependiente; o (e) Por notificación escrita del Asegurador como se establece en las condiciones de esta póliza. Aviso requerido por el asegurador EL ASEGURADO DEBE CONTACTAR A LA ADMINISTRADORA DE RECLAMOS DEL ASEGURADOR, USA MEDICAL SERVICES, POR LO MENOS SETENTA Y DOS (72) HORAS ANTES DE RECIBIR CUALQUIER CUIDADO MéDICO. EL TRATAMIENTO DE EMERGENCIA DEBE SER NOTIFICADO DENTRO DE LAS CUARENTA Y OCHO (48) HORAS SIGUIENTES AL INICIO DEL TRATAMIENTO. SI EL ASEGURADO NO ENTRA EN CONTACTO CON USA MEDICAL SERVICES COMO SE HA ESTABLECIDO PREVIAMENTE, EL ASEGURADO SERá RESPONSABLE POR EL TREINTA POR CIENTO (30%) DE TODOS LOS GASTOS CUBIERTOS DE MéDICOS Y HOSPITALES RELACIONADOS CON LA RECLAMACIóN, EN ADICIóN AL DEDUCIBLE Y AL COASEGURO (SI ES APLICABLE). USA Medical Services puede ser contactado las 24 horas del día, los 365 días del año a los siguientes números de teléfono: En los EE.UU.: (305) Sin cobro desde los EE.UU.: Fax: (305) Correo electrónico a: claims@usamedicalservices.com Fuera de los EE.UU.: EL NÚMERO DE TELéFONO PUEDE SER ENCONTRADO EN SU TARJETA DE IDENTIDAD O EN TABLA DE BENEFICIOS (VEA LA SECCIóN CORRESPONDIENTE DE LA PóLIZA PARA DETALLES, LIMITACIONES Y RESTRICCIONES). EXCEPTO SI SE MENCIONA LO CONTRARIO, LOS ASEGURADOS BAJO ESTA PóLIZA NO TIENEN EL REQUISITO DE OBTENER TRATAMIENTO DENTRO DE LA RED DE PROVEEDORES PREFERIDOS. LA COBERTURA MáXIMA ES DE CINCO MILLONES DE DóLARES ($5,000,000) POR ASEGURADO, DE POR VIDA, POR TODOS LOS GASTOS MéDICOS Y DE HOSPITALES CUBIERTOS DURANTE LA VIGENCIA DE LA PóLIZA, SUJETA A LOS LíMITES QUE SE INDICAN A CONTINUACIóN: Cobertura Beneficio Máximo En la Red de Proveedores Preferidos Fuera de la Red de Proveedores Preferidos 1. Habitación estándar de hospital privada o semiprivada y alimentación Sin Límite $800 por día 2. Unidad de cuidados intensivos y alimentación Sin Límite $2,000 por día Los siguientes beneficios aplican a todos los Proveedores: 3. Cuidados de maternidad (excepto los planes C Plus, D y E) (no se aplican deducible ni coaseguro) $4, Cobertura del recién nacido (no se aplican deducible ni coaseguro) $25, Condiciones congénitas y hereditarias: Manifestadas antes de la edad de 18 años (por Asegurado, de por vida) $250,000 Manifestados a la, o después de, la edad de 18 años (por Asegurado, de por vida) $5,000, Trasplante de órganos (por Asegurado, de por vida) $500, Transporte por ambulancia aérea (por Asegurado, de por vida) $100,000 2 Plan Bupa Worldwide 0112

19 Cobertura Beneficio Máximo 8. Transporte por ambulancia terrestre (por incidente) $1, Acompañante de menor hospitalizado (por hospitalización) $1, Repatriación de restos mortales $5,000 Deducible Un (1) deducible por Asegurado, por año póliza, hasta el máximo del deducible fuera del país de residencia. Máximo dos (2) deducibles por póliza, por año póliza. Si un deducible en el país de residencia ha sido cubierto y además hay servicios médicos proporcionados fuera del país de residencia, la diferencia entre los deducibles en el país de residencia y fuera del país de residencia será responsabilidad del Asegurado. Cualquier gasto elegible en que incurra el Asegurado durante los tres (3) últimos meses del año póliza y que sea usado para satisfacer el deducible de ese año póliza, será transferido y aplicado al deducible del Asegurado para el siguiente año póliza. Coaseguro El Asegurado es responsable por el veinte por ciento (20%) de los primeros cinco mil dólares ($5,000) de gastos aprobados después de satisfacer el deducible establecido (excepto los planes C Plus, D y E). Un (1) coaseguro por Asegurado, por año póliza. En el caso de un accidente que involucre a múltiples miembros de una familia asegurada bajo la misma póliza, se aplicará un máximo de dos (2) coaseguros para este incidente. Otros coaseguros para enfermedades o lesiones no relacionadas con el accidente pueden ser aplicados a los miembros de la familia a quienes no se les aplicó un coaseguro. Si se notifica a USA Medical Services como es requerido en la póliza, el coaseguro no será aplicado a los servicios médicos recibidos en el país de residencia. DEFINICIONES 1. ACCIDENTE: Cualquier evento súbito e imprevisto producido por una causa externa del cual resulta una lesión. 2. TRANSPORTE POR AMBULANCIA AéREA: Transportación aérea de emergencia desde el hospital donde el Asegurado está ingresado hasta el hospital más cercano donde el tratamiento médico adecuado puede ser proporcionado. 3. ENMIENDA: Documento añadido a la póliza por el Asegurador que aclara, explica o modifica la póliza. 4. HONORARIOS DE ANESTESISTAS: Cargos de un anestesista por la administración de anestesia para la realización de un procedimiento quirúrgico o servicios médicamente necesarios para controlar el dolor. 5. FECHA DE ANIVERSARIO: Ocurrencia anual de la fecha de efectividad de la póliza. 6. SOLICITANTE: La persona que firmó la solicitud para cobertura. 7. SOLICITUD: Declaración escrita en un formulario por un propuesto Asegurado sobre sí mismo y sus dependientes, usada por el Asegurador para determinar la aceptación o denegación del riesgo. La solicitud incluye cualquier historial médico, cuestionario, y otros documentos proporcionados a o solicitados por el Asegurador antes de la emisión de la póliza. 8. HONORARIOS DEL MéDICO / CIRUJANO ASISTENTE: Cargos del médico o médicos que asisten al cirujano principal en la realización de un procedimiento quirúrgico. 9. AÑO CALENDARIO: Del 1o. de enero al 31 de diciembre del mismo año. Ni la aseguradora, ni USA Medical Services, ni ninguna de sus filiales o subsidiarias pertinentes relacionadas participarán en transacciones con cualquier parte o país donde dichas transacciones estén prohibidas por las leyes de los Estados Unidos de América. Por favor comuníquese con USA Medical Services para obtener más información sobre esta restricción. 10. CERTIFICADO DE COBERTURA: Documento de la póliza que especifica el comienzo, las condiciones, la extensión y cualquier limitación de la cobertura y enumera todas las personas cubiertas. 11. CLASE: Los asegurados de todas las pólizas de un mismo tipo, incluyendo pero no limitado a beneficios, deducible, grupo de 3 Plan Bupa Worldwide 0112

20 edad, país, plan, año de póliza o una combinación de cualesquiera de éstos. fuera del país de residencia están sujetos a un deducible fuera del país de residencia. 12. COASEGURO: Es la porción de las facturas médicas cubiertas que el Asegurado debe pagar en adición al deducible. 19. CENTRO MéDICO DE DIAGNóSTICO: Instalación médica debidamente autorizada para realizar exámenes físicos completos. 13. COMPLICACIONES DEL NACIMIENTO: Cualquier desorden de un recién nacido relacionado con el nacimiento pero no causado por factores genéticos, que se manifiesta durante los primeros treinta y un (31) días de vida, incluyendo pero no limitado a, hiperbilirrubinemia (ictericia), hipoxia cerebral, hipoglicemia, prematuridad, déficit respiratorio, o traumatismos durante el parto. 14. DESóRDENES O ENFERMEDADES CONGéNITAS O HEREDITARIAS: Cualquier desorden o enfermedad existente antes del nacimiento, independientemente de la causa y de si se manifestó o fue diagnosticado al momento del nacimiento, después del nacimiento o años después. 15. PAíS DE RESIDENCIA: El país: (1) Donde el Asegurado reside la mayor parte del año calendario o del año póliza; o (2) Donde el Asegurado ha residido por más de ciento ochenta (180) días continuos durante cualquier período de trescientos sesenta y cinco (365) días mientras la póliza está en vigor. 16. MATERNIDAD CUBIERTA: Las maternidades cubiertas son aquellas en que la fecha del parto es por lo menos doce (12) meses posterior a la fecha de cobertura de la madre asegurada. Los planes C Plus, D y E no tienen cobertura de maternidad. 17. CUIDADOS DE CUSTODIA: Servicios proporcionados que incluyen, pero no están limitados a, habitación, comida y asistencia personal que no requieren la destreza de un profesional y que generalmente son proporcionados durante largos períodos. Asistencia con las actividades de la vida diaria que pueden ser proporcionadas por personal sin entrenamiento médico o de enfermería (bañarse, vestirse, asearse, alimentarse, usar el baño, etc.). 18. DEDUCIBLE: Es la cantidad de los gastos cubiertos que debe ser pagada por el Asegurado antes de que los beneficios de la póliza sean pagables. Los gastos incurridos en el país de residencia están sujetos al deducible en el país de residencia. Los gastos incurridos 20. FECHA DE VENCIMIENTO: La fecha en que la prima es debida y pagable. 21. FECHA EFECTIVA: Fecha en que comienza la cobertura bajo la póliza, tal como aparece en el Certificado de Cobertura. Esta fecha solo será efectiva después que la póliza de seguro haya sido entregada al Asegurado y que haya expirado el Derecho de Diez (10) Días para Examinar la Póliza. 22. EMERGENCIA: Una condición médica que se manifiesta por signos o síntomas agudos que pueden razonablemente resultar en peligro inmediato para la vida o para la integridad física del Asegurado si no se proporciona atención médica dentro de las veinticuatro (24) horas siguientes. 23. TRATAMIENTO DENTAL DE EMERGENCIA: Tratamiento necesario para restaurar o reemplazar los dientes naturales dañados o perdidos en un accidente cubierto. 24. TRATAMIENTO DE EMERGENCIA: Tratamiento médicamente necesario debido a una emergencia. 25. PERíODO DE GRACIA: El período de tiempo de treinta (30) días después de la fecha de vencimiento, durante el cual el Asegurador permitirá que la póliza sea renovada. 26. TRANSPORTACIóN POR AMBULANCIA TERRESTRE: Transportación de emergencia hacia un hospital por una ambulancia terrestre. 27. ACTIVIDADES PELIGROSAS: Cualquier actividad que expone al participante a un riesgo o peligro previsible. Ejemplos de actividades peligrosas incluyen, pero no están limitados a, deportes de aviación, deportes en balsas o canoas en aguas rápidas que excedan grado 5, competencias de velocidad, buceo a una profundidad de más de 30 metros, bungee jumping, participación en cualquier deporte 4 Plan Bupa Worldwide 0112